58-year-old man with confusion and agitation
A 58-year-old man with a history of schizoaffective disorder and type 2 diabetes is brought to the emergency department by his wife because of 24 hours of increasing confusion and agitation. His medications include sertraline, olanzapine, and metformin. He recently completed a 10-day course of linezolid for a non-healing foot ulcer. Temperature is 38.6°C (101.5°F), heart rate is 125/min, blood pressure is 170/95 mmHg, and respiratory rate is 22/min. On examination, he is diaphoretic and disoriented. Pupils are 7 mm and reactive. He has a prominent tremor in his upper extremities. Lower extremity examination shows 3+ deep tendon reflexes and inducible clonus at both ankles. Muscle tone is increased throughout but there is no lead-pipe rigidity. Which of the following is the most appropriate next step in management?
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D
Explanation
Clinical Pearl:
Serotonin syndrome is distinguished from neuroleptic malignant syndrome by neuromuscular findings: hyperreflexia and clonus are characteristic of SS, while severe 'lead-pipe' rigidity and hyporeflexia are typical of NMS.
Explanation:
This patient's presentation with altered mental status, autonomic hyperactivity (fever, tachycardia, hypertension), and neuromuscular excitation (hyperreflexia, inducible clonus) after exposure to two serotonergic agents (sertraline and linezolid) is diagnostic of serotonin syndrome. The most appropriate initial management is to discontinue the offending agents and provide supportive care. For agitation, muscle hyperactivity, and autonomic instability associated with moderate serotonin syndrome, benzodiazepines are the first-line treatment. Therefore, administering lorazepam is the correct next step. Dantrolene and bromocriptine are treatments for neuroleptic malignant syndrome, which is characterized by lead-pipe rigidity and hyporeflexia, findings absent in this patient. Haloperidol is contraindicated as it can worsen NMS and has no therapeutic role in serotonin syndrome. Cyproheptadine, a serotonin antagonist, is typically reserved for moderate-to-severe cases that do not respond to supportive measures and benzodiazepines.
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